Femoral Shaft Fractures

In most centers, the cast is applied in the operating
room or sedation unit. For the sitting spica cast technique, a long leg
cast is placed with the knee and ankle flexed at 90 degrees (Fig. 22-9A). Knee flexion of more than 60 degrees improved maintenance of length and reduction.¹⁰⁰ However, if one applies excessive traction to maintain length (Fig. 22-10),
the risk of compartment syndrome is unacceptably high. Less traction,
less knee flexion, and accepting slightly more shortening is a
reasonable compromise. Extra padding, or a felt pad, is placed in the
area of the popliteal fossa. The knee should not be flexed after
padding because this may create vascular obstruction by producing a
lump of material in the popliteal fossa (Fig. 22-9B). Because most diaphyseal fractures tend to fall into varus angulation

while in a spica cast, a valgus mold is necessary (Fig. 22-9C).
The patient is then placed on a spica table, supporting the weight of
the legs with manual traction, and the remainder of the cast is applied
with the hips in 90 degrees of flexion and 30 degrees of abduction,
holding the fracture out to length (Fig. 22-9D).
It is mandatory to avoid excessive traction because compartment
syndromes and skin sloughs have been reported. The leg should be placed
in 15 degrees of external rotation to align the distal fragment with
the external rotation of the proximal fragment. After the spica cast is
in place, AP and lateral radiographs are obtained to ensure that length
and angular and rotational alignment are maintained. We observe all
patients for 24 hours after spica application to be sure that the child
is not at risk for neurovascular compromise or compartment syndrome.
Gore-tex liners can be used to decrease the skin problems of diaper
rash and superficial infection. Several centers have found that this
has been beneficial, justifying the cost of a Gore-tex liner.

For the single-leg spica or walking spica technique, the
long-leg cast is applied with approximately 50 degrees of knee flexion,
and when the remainder the cast is placed, the hip is flexed 45 degrees
and externally rotated 15 degrees. The hip should be reinforced
anteriorly with multiple layers of extra fiberglass. The pelvic band
should be fairly wide so that the hip is controlled as well as
possible. A substantial valgus mold is important to prevent varus
malangulation. Increasingly, we have been leaving the foot out,
stopping the distal end of the cast in the supramalleolar area, which
is protected with plenty of extra

padding.
Seven to 10 days after injury is the perfect window of time to wedge
the cast and correct small amounts of shortening and varus angulation
which commonly occur. Most toddlers pull to a stand and begin walking
in their walking cast about 2 to 3 weeks after injury.

If excessive angulation occurs, the cast should be
changed with manipulation in the operating room. Casts can be wedged
for less than 15 degrees of angulation. If shortening of more than 2 cm
is documented, the child should be treated with cast change, traction,
or conversion to external fixation, using lengthening techniques if the
shortening is not detected until the fracture callus has developed.
When conversion to external fixation is required, we recommend
osteoclasis (either closed or open if needed) at the time of the
application of the external fixator, with slow lengthening over a
period of several weeks (1 mm per day) to re-establish acceptable
length (see Fig. 22-8).

Generally, the spica cast is worn for 4 to 8 weeks,
depending on the age of the child and the severity of the soft tissue
damage accompanying the fracture. Typically, an infant’s femoral shaft
fracture will heal in 3 to 4 weeks; and a toddler’s fracture will heal
in 6 weeks. After the cast hass been removed, parents are encouraged
allow their child to stand and walk whenever the child is comfortable;
most children will need to be carried or pushed in a stroller for a few
days until hip and knee stiffness gradually results. Most joint
stiffness resolves spontaneously in children after a few weeks. It is
unusual to need formal physical therapy. In fact, aggressive joint
range-of-motion exercises with the therapist immediately after cast
removal makes children anxious and may prolong rather then hasten
recovery. A few follow-up visits are recommended in the first year
after femoral fracture, analyzing gait, joint range of motion, and leg
lengths.

After preparation of the thigh circumferentially from
the knee to the midthigh, the limb is draped in a sterile manner. The
knee is held in the position in which it will remain during traction;
that is, if 90/90 traction is being used, the traction pin should be
inserted with the knee bent 90 degrees. The patient should be sedated
and the wound treated with a local anesthetic, or general anesthesia
should be given before the traction pin is inserted. The location of
pin insertion is one finger breadth above the patella with the knee
extended or just above the flare of the distal femur. A small puncture
wound is made over the medial side of the femur. A medial-to-lateral
approach is used so that the traction pin does not migrate into the
area of the femoral artery that runs through Hunter’s canal on the
medial side of the femur. A traction pin between 3/32 inch and 3/16
inch is chosen depending on the size of the child. The pin is placed
parallel to the joint surface⁵ to help maintain alignment

while in traction. After the pin protrudes through the lateral cortex
of the femur, a small incision is made over the tip of the pin. The pin
is then driven far enough through the skin to allow fixation with a
traction bow. If 90/90 traction is used, a short leg cast is placed
with a ring through its midportion to support the leg. Alternatively, a
sling to support the calf can be used. If a sling is used, heel cord
stretching should be done while the patient is in traction.

After the skeletal traction pin has been placed in the
distal femur, traction is applied in a 90/90 position (the hip and knee
flexed 90 degrees) (Fig. 22-12) or in an
oblique position (the hip flexed 20 to 60 degrees). If the oblique
position is chosen, a Thomas splint or sling is necessary to support
the leg. The fracture may be allowed to begin healing in traction, and
radiographs should be obtained once or twice a week to monitor
alignment and length. In preschool-age children, traction will be
necessary for 2 to 3 weeks; in school-age children, a full 3 weeks of
traction usually are necessary before the fracture is stable enough to
permit casting. In a child under 10 years of age, the ideal fracture
position in traction should be less than 1 cm of shortening and slight
valgus alignment to counteract the tendency to angulate into varus in
the cast and the eventual overgrowth that may occur (average 0.9 cm).
If this method is used for adolescents (11 years or older), normal
length should be maintained.

Traction of 3 weeks or more followed by immobilization
in a spica cast is well tolerated by young children. In older children,
maintaining the knee in 90 degrees of flexion for a prolonged period
may lead to knee stiffness and a difficult period of rehabilitation.⁹⁷

In a study by Gross et al.,⁷³
72 children with femoral fractures were treated with early cast
brace/traction management. In this technique, a traction pin is placed
in the distal femur and then incorporated in a cast brace. The traction
pin is left long enough

to
be used for maintaining traction while the patient is in the cast brace
or traction is applied directly to the cast. The patient is allowed to
ambulate in the cast brace starting 3 days after application.
Radiographs are taken of the fracture in the cast brace to document
that excessive shortening is not occurring. The patient is then
returned to traction in the cast brace until satisfactory callus is
present to prevent shortening or angular deformity with weight bearing.
The technique was not effective in older adolescents with midshaft
fractures but achieved excellent results in children 5 to 12 years of
age. The average hospital stay was 17 days.

Comparative studies and retrospective reviews have
demonstrated unsatisfactory results in a small, yet significant,
percentage of patients treated with skeletal traction.⁹⁰,⁹⁷,¹¹³,¹⁷⁰ Recently, increased attention has been focused on the risk of compartment syndrome in children treated in 90/90 spica cast.¹⁵² Mubarak et al.¹⁵²
presented a multicenter series of 9 children with an average age of 3.5
years who developed compartment syndrome of the leg after treatment of
a low-energy femoral fracture in a 90/90 spica cast. These children had
extensive muscle damage and the skin loss around the ankle (Fig 22-13).
The authors emphasized the risk in placing an initial below-knee cast,
then using that cast to apply traction while immobilizing the child in
the 90/90 position. The authors recommended avoiding traction on a
short leg cast, leaving the foot out, and using less hip and knee
flexion (Fig 22-14).

Flexible intramedullary nailing of pediatric femoral
fractures, a dominant technique in Europe since the 1970s, has been
rapidly adopted throughout North America as the most popular method of
fixation for midshaft femoral fractures in children between the ages of
5 and 11 years. The flexible intramedullary nailing technique can be
done with either stainless steel nails¹⁶⁹ or titanium elastic nails.

The popularity of flexible intramedullary nailing is a
result of safety and efficacy. Safety and complications were a concern
with two methods of rigid fixation: solid antegrade nailing
(osteonecrosis) and external fixation (pin site infection, refracture
after external fixator removal). The flexible nailing technique offered
satisfactory fixation, enough stress at the fracture site to allow
abundant callus formation, and relatively easy insertion and removal.
The implants are inexpensive and the technique has a short learning
curve. The primary limitation of flexible nailing is the lack of rigid
fixation. Length-unstable fractures can shorten and angulate,
especially in older and heavier children. Compared to children with
rigid fixation, children who have their femoral fracture treated with
flexible nailing clearly have more pain and muscle spasm in the early
postoperative period. The surgeon should take this into consideration
in planning the early rehabilitation.

As the flexible nailing technique has become more
popular, there have been many studies to refine the technique and
indications and to elucidate the inherent limitations of fixation with
flexible implants. Mechanical testing of femoral fracture fixation
systems showed that the greatest rigidity is provided by an external
fixation device and the least by flexible intramedullary rodding.¹²⁰
Stainless steel rods are stiffer than titanium in bending tests. A
study comparing steel to titanium flexible nails found a higher
complication rate in the titanium group.²⁰⁶ They reported that a typical 3.5-mm stainless steel nail has the same strength as a 4.0-mm titanium nail. Lee et al.¹²⁰
analyzed a group of synthetic fractured femurs instrumented with Enders
rods and determined that there was sufficient axial and torsional
stiffness to allow “touch down weight-bearing” despite fracture type.
Gwyn et al.⁷⁶ similarly showed that
4-mm titanium rods imparted satisfactory torsional stability regardless
of fracture pattern. Recognizing this flexibility, the French pioneers¹¹⁹,¹²³
of elastic nailing stressed the critical importance of proper implant
technique, including prebending the nails so that the apex of the bend
was at the fracture site, and so that the two implants balance one
another to prevent bending and control rotation. Frick et al.⁶⁵
found greater stiffness and resistance to torsional deformation when
retrograde nails were contoured into a double C pattern than with the
antegrade C and S configuration.

The prevailing technique for flexible nail insertion at
most centers throughout the world has been retrograde, with small
medial and lateral incisions just above the distal femoral physis;
however, some prefer an antegrade technique, with entry in the
subtrochanteric area. The primary advantages of a proximal insertion
site are a fewer knee symptoms postoperatively. Bourdela²²
compared retrograde and antegrade (ascending and descending) flexible
intramedullary rodding in a group of 73 femoral fractures. Sixty one
fractures were treated with antegrade nails and 12 with retrograde
nails. All children with antegrade nailing had good clinical and x-ray
results; all 12 children with retrograde nails had knee pain that
impaired knee motion until the nails were removed. An antegrade
transtrochanteric approach was recommended by Carey and Galpin,³²
who reported excellent results in 25 patients without growth arrest of
the upper femur and no osteonecrosis. Satisfactory alignment and
fracture healing were obtained in all patients.

Retrograde intramedullary nailing with Ender nails or titanium nails has been reported by Ligier et al.,123 Mann et al.,¹³⁰ Heinrich et al.,⁸⁶ Herscovici et al.,⁹¹ and others.³²,¹¹⁰,¹³⁷ Heinrich et al.⁸⁶
recommended a 3.5-mm Ender nail in children 6 to 10 years of age and a
4.0-mm nail in children over 10 years of age. Ligier et al.¹²³ used titanium nails ranging from 3 to 4 mm inserted primarily in a retrograde fashion. Heinrich et al.⁹¹
recommended flexible intramedullary nails for fixation of diaphyseal
femoral fractures in children with multiple system injury, head injury,
spasticity, or multiple long bone fractures. Flynn et al.⁶²
published the first North American experience with titanium elastic
nails in 2001. In this multicenter study, 57 of 58 patients had an
excellent or satisfactory result and there was no loss of rotational
alignment, but 4 patients healed with an angular malunion of more than
10 degrees. Narayanan et al.¹⁵³
looked at one center’s learning curve with titanium elastic nails,
studying the complications of 79 patients over a 5-year period. Nails
that were bent excessively away from the bone led to irritation at the
insertion site in 41. The center also had eight malunions and two
refractures. They noted that complications could be diminished by using
rods with similar diameter and contour and by avoiding bending the
distal end of the nail way from the bone. Luhmann et al.¹²⁶
reported 21 complications in 43 patients with titanium elastic nails.
Most of the problems were minor, but a hypertrophic nonunion and a
septic joint occurred in their cohort. They suggested that problems
could be minimized by using the largest nail possible and leaving only
2.5 cm out of the femoral cortex.

Flexible nails are removed after fracture union at most
centers; however, some surgeons choose to leave the implants
permanently. There is a theoretical concern that if flexible nails are
left in young children, they will come to lie in the distal diaphysis
as the child grows older. This may create a stress riser in the distal
diaphysis, leading to a theoretical risk of fracture (Fig. 22-15). Morshed et al.¹⁵¹ performed a retrospective analysis of

24 children treated with titanium elastic nails and followed for an
average of 3.6 years. The original plan with these children was to
retain their implants, but about 25% of the children had their nails
removed because of persistent discomfort.

External fixation of femoral shaft fractures offers an
efficient, convenient method to align and stabilize the fractured
pediatric femur. It is the method of choice when severe soft tissue
injury is present, and may be considered in any patient where
traditional closed methods of management are not appropriate.¹¹⁶
In head-injured or multiply-injured patients and those with open
fractures, external fixation offers an excellent method of rapid
fracture stabilization. It is also valuable for very proximal or distal
fractures, where options for flexible nailing, plating, or casting are
limited. External fixation is particularly valuable for benign
pathologic fractures (e.g., through a nonossifying fibroma) at the
distal metaphyseal-diaphyseal junction (Fig. 22-20), where the fracture will heal rapidly, but minimal angular malunion can be tolerated.

Aronson and Tursky⁶
reported their early experience with 44 femoral fractures treated with
primary external fixation and early weight bearing. Most patients
returned to school by 4 weeks after fracture and had full knee motion
by 6 weeks after the fixator was removed. In this early study, end-on
alignment was the goal and overgrowth was minimal. More recently,
Matzkin et al.¹³³ reported a series
of 40 pediatric femoral fractures treated with external fixation; 72%
of the fixators were dynamized before removal, and their refracture
rate was only 2.5%. They had no overgrowth, but one patient ended up 5
cm short.

Following early enthusiasm for the use of external
devices, the 1990s saw waning interest in their use because of
complications with pin track infections, pin site scarring, delayed
union, and refracture. These complications, coupled with the very low
complication rate from flexible nailing, led to a decline of external
fixation for pediatric femoral shaft fractures. Data from comparison
studies also contributed to the change. Bar-On et al.⁹
compared external fixation with flexible intramedullary rodding in a
prospective randomized study. They found that the early postoperative
course was similar but that the time to return to school and to resume
full activity was less with intramedullary fixation. Muscle strength
was better in the flexible intramedullary fixation group at 14 months
after fracture. Parental satisfaction was also significantly better in
the flexible intramedullary rodding group. Bar-On et al.⁹ recommended that external fixation be reserved for open or severely comminuted fractures.

In general, circular fixation devices are rarely, if
ever, indicated for femoral fractures in young children. One of two
types of monolateral devices are typically used. The AO system, in
which pins can be placed at any point along a bar, with a special clamp
holding the pins at a variable angle to the bar has been used at many
centers. The advantage of this system is that the stability of fixation
is increased if the two pins on each side of the fracture are spread
widely, with one pin close to the fracture and one quite distant from
it. A second longitudinal rod can be added to this system to increase
its rigidity. A second type of external fixation system has pin clamps
at the end of a telescopic tube. The pin clamps provide easy
application, but the stability of the fixation device is decreased
because the pins are widely separated from the fracture. The pin clamps
may be constrained to rotation only (Wagner) or attached with a
universal joint to the barrel of the device (Orthofix, EBI) (Fig. 22-21).
The telescoping barrel provides lengthening or “dynamization,” and the
universal joints provide adjustment. Dynamization refers to the amount
of longitudinal motion allowed by a given frame or construct. A
fracture can be dynamized before frame removal to increase strength of
healing callus. Different external fixation devices allow for varying
amounts of dynamization. Excessive rigidity is thought to relate to
poor bone healing and strength. For this reason, many pediatric trauma
experts purposely build a less stable frame to increase the forces on
the fracture site. Pins are more closely clustered and placed farther
from the fracture site, and the frame itself is placed more laterally
away

from the femur. Domb et al.⁵²
compared static to dynamic external fixation in pediatric femoral
fractures. Average time to early callus formation was similar, and the
average time to complete healing was 70.1 days in the dynamic group and
63.1 days in the static group. The assumption that less rigid frames
decrease fracture healing remains unproven. The problem may be that
smaller, lighter children simply do not place enough force across the
dynamized fracture to stimulate callus production.

The ease and speed with which an external fixation
device can be applied make it ideal for management of a polytrauma
victim who cannot tolerate extended anesthesia. Nowotarski et al.,¹⁵⁸
in a review of 1507 femoral fractures at a trauma center, found 59 (4%)
that were managed with urgent external fixation followed by
intramedullary rodding. The average time to rodding was 7 days, and the
infection rate was 1.7% (1 patient). They concluded that emergent
external fixation followed by early intramedullary rodding was safe.

During preoperative planning, the fracture should be
studied carefully for comminution or fracture lines that propagate
proximally or distally. The surgeon should assure that the fixator
devices available are long enough to span the distance between the
optimal proximal and distal pin insertion sites.

As in the elastic nailing technique, either a fracture
table or radiolucent table can be used, although a fracture table is
much more efficient because an anatomic reduction can be obtained
before preparation and draping. First, the fracture is reduced both in
length and alignment. If the fracture is open, it should be irrigated
and débrided before application of the external fixation device. With
the fracture optimally aligned, fixation is begun. The minimal and
maximal length constraints characteristic of all external fixation
systems must be kept in mind, and the angular adjustment intrinsic to
the fixation device should be determined. Rotation is constrained with
all external fixation systems once the first pins are placed. That is,
if parallel pins are placed with the fracture in 40 degrees of
malrotation, a 40-degree malalignment will exist. Rotational correction
must be obtained before placing the pins in the proximal and distal
shafts of the femur.

Application of the fixator is similar no matter what
device is chosen. One pin is placed proximally in the shaft, and
another pin is placed distally perpendicular to the long axis of the
shaft. Alignment is based on the long axis of the shaft, rather than
the joint surface. Rotation should be checked before the second pin is
placed because it constrains rotation but not angulation or length.
After pins are correctly placed, all fixation nuts are secured and
sterile dressings are applied to pins.

The most common complication of external fixation is pin
track irritation or infection, which has been reported to occur in up
to 72% of patients.¹⁴⁷ This problem generally is easily treated with oral antibiotics and local pin site care. Sola et al.¹⁸⁹
reported a decreased number of pin track infections after changing
their pin care protocol from cleansing with peroxide to simply having
the patient shower daily. Superficial infections should be treated
aggressively with pin track releases and antibiotics. Deep infections
are rare, but if present, surgical débridement and antibiotic therapy
are usually effective. Any skin tenting over the pins should be
released at the time of application or at follow-up.

In a study of complications of external fixators for femoral fractures, Gregory et al.⁷⁰
reported a 30% major complication rate and a high minor complication
rate. Among the major complications were five refractures or fractures
through pin sites. Another comprehensive study of external fixation
complications³³ found an overall rate of refracture of 4.7%, with a pin track infection rate of 33.1%. Skaggs et al.¹⁸⁷
reviewed the use of external fixation devices for femoral fractures and
found a 12% rate of secondary fractures in 66 patients. Multivariate
linear regression analysis showed no correlation between the incidence
of refracture and the fracture pattern, percentage of bone contact
after fixator application, type of external fixator used, or
dynamization of the fracture. A statistically significant association
was found between the number of cortices demonstrating bridging callus
on both the AP and lateral views at the time of fixator removal and
refracture. Fractures with fewer than three cortices with bridging
callus at the time of fixator removal had a 33% risk of refracture,
whereas those with three or four cortices showing bridging callus had
only a 4% rate of refracture. Other reports in the literature with
smaller numbers, but still substantial experience, document refracture
rates as high as 21.6% with more significant complications.⁴⁷,⁴⁸,⁷¹,⁹⁶,¹⁴⁷,¹⁶⁷,¹⁸⁴ In 1997, in a follow-up of the original article by Aronson and Tursky,⁶ Blasier et al.¹⁹
reported 139 femoral fractures treated with external fixation; they
found that pin track infection was common and there was a 2% incidence
of fracture after removal of the device. El Hayek et al.⁵⁴
demonstrated the benefit of modern techniques of external fixation in a
series of 28 fractures in 21 children. Despite the complications,
patients and treating physicians have found wound care and ability to
lengthen through the fracture to be of great benefit with this
technique.

Although joint stiffness has been noted in older
patients treated with external fixation, it is relatively uncommon in
children with femoral fractures unless major soft tissue injury is
present.⁵⁷

With reports by Beaty et al.¹¹
and others in the early 1990s alerting surgeons that antegrade
intramedullary nailing can be complicated by osteonecrosis of the
proximal femur, flexible nailing (either antegrade or retrograde)
quickly became more popular than standard locked, antegrade rigid
intramedullary nailing. Recently, however, locked antegrade femoral
nailing for pediatric femoral fractures has enjoyed a resurgence of
interest with the introduction of newer generation implants that allow
a very lateral trochanteric entry point. These newer implant systems
avoid a piriformis entry site, reducing (but perhaps not completely
eliminating) the risk of osteonecrosis. Others have adapted humeral
nails for pediatric femoral fractures.¹⁶
Antegrade locked intramedullary fixation is particularly valuable for
femoral fractures in adolescents. Comparative studies by Reeves et al.¹⁷⁰ and Kirby et al.,¹¹³
as well as retrospective reviews of traction and casting, suggest that
femoral fractures in adolescents are better treated with intramedullary
fixation¹¹,³⁰,⁴⁷,⁶⁸,⁶⁹,⁷³,⁹⁰,¹⁰⁸,¹¹³,¹²³,¹⁹⁷,²¹⁰,²¹² than with traditional traction and casting (Table 22-3). Kanellopoulos et al.¹⁰⁷
reported excellent results in 20 skeletally immature patients, ranging
in age from 11 to 16 years, treated with closed, locked intramedullary
nailing through the tip of the greater trochanter. There were no
complications, including no osteonecrosis, with an average follow-up of
29 months.

Length-unstable adolescent femoral fractures benefit
from interlocking proximally and distally to maintain length and
rotational alignment.¹²,²⁵,⁷⁸ Beaty et al.¹¹
reported the use of interlocking intramedullary nails for the treatment
of 31 femoral shaft fractures in 30 patients 10 to 15 years of age. All
fractures united, and the average leg length discrepancy was 0.51 cm.
No angular or rotational malunions occurred. All nails were removed at
an average of 14 months after injury; no refracture or femoral neck
fracture occurred after nail removal. One case of osteonecrosis of the
femoral head occurred, which was thought to be secondary to injury to
the ascending cervical artery during nail insertion.

Reamed antegrade nailing in children with an open
proximal femoral physis must absolutely avoid the piriformis fossa, due
to the risk of proximal femoral growth abnormalities,¹⁶⁸ the risk of osteonecrosis of the femoral head,¹¹,¹⁴³,¹⁶⁶,¹⁹⁴ the size of the proximal femur, and the relative success of other treatment methods. However, Maruenda-Paulino et al.¹³¹ reported good results using 9-mm Kuntscher rods in children 7 to 12 years of age, and Beaty et al.¹¹
reported the use of pediatric “intermediate” interlocking nails for
femoral canals with diameters as small as 8 mm. Townsend and Hoffinger²⁰⁰ and Momberger et al.¹⁴⁸
published reviews of trochanteric nailing in adolescents with very good
results. The combined series included 82 patients aged 10 to 17 with
follow-up of 6 years with no reported

cases of osteonecrosis and no significant alteration in proximal femoral anatomy.

Open fractures in older adolescents can be effectively
treated with intramedullary rodding, either as delayed or primary
treatment, including those caused by gunshot wounds and high-velocity
injuries.¹⁵,¹⁹⁸
Antegrade intramedullary rod insertion maintains length, prevents
angular malunion and nonunion, and allows the patient to be rapidly
mobilized and discharged from the hospital. However, other techniques
with fewer potential risks should be considered.

Retrograde rodding of the femur has become an accepted procedure in adults.¹⁶¹,¹⁷²
In a large patient approaching skeletal maturity (bone age >16
years) but with an open proximal femoral physis and an unstable
fracture pattern, this treatment might be considered as a way to avoid
the risk of osteonecrosis yet stabilize the fracture (Fig. 22-22).
If growth from the distal femur is predicted to be less than 1 cm, leg
length inequality should not be a problem. Ricci et al.¹⁷²
have shown that the complication rate with this technique compares
favorably to that of antegrade nailing, with a higher rate of knee pain
but a lower rate of hip pain. The malunion rate was slightly lower with
retrograde rodding than with antegrade rodding of the femur.

The patient is placed either supine or in the lateral
decubitus position on a fracture table. The upper end of the femur is
approached through a 3-cm longitudinal incision proximal that allows
access to the lateral trochanteric entry point. The skin incision can
be precisely placed after localization on both the AP and lateral
views. Dissection should be limited to the lateral aspect of the
greater trochanter, avoiding the piriformis fossa. This prevents
dissection near the origin of the lateral ascending cervical artery
medial to the piriformis fossa. The rod should be inserted through the
lateral aspect of the greater trochanter. In children and adolescents,
it is preferable to choose the smallest implant with the smallest
diameter reaming to avoid damage to the proximal femoral insertion area.

The technique for reaming and nail insertion varies
according to the specifics of the implant chosen. In general, the
smallest rod that maintains contact with the femoral cortices is used
(generally 9 mm or less) and is locked proximally and distally (Fig. 22-23). Only one distal locking screw is necessary, but two can be used.¹¹²
Rods that have an expanded proximal cross-section should be avoided,
because they require excessive removal of bone from the child’s
proximal femur. The proximal end of the nail should be left slightly
long (up to 1 cm) to make later removal easier. The rod chosen should
be angled proximally and specifically designed for transtrochanteric
insertion (Fig. 22-24).

The injured thigh is prepared and draped on a
radiolucent operating table. The femur is approached laterally. The
vastus lateralis is retracted anteriorly to expose the femur. Soft
tissue attachments to the bone are preserved to the extent possible.
Fragments are lagged into place and secured with a DCP. A 4.5-mm or
larger compression plate is used in children. If the fracture is at
either end of the bone, leaving insufficient bone for cortical
fixation, fully threaded cancellous screws add to the stability of
fixation and are preferable to either cortical or partially threaded
cancellous screws. Both interfragmentary compression and dynamic
compression techniques can be used to achieve stability and anatomic
alignment. Locking screws are rarely necessary and may be difficult to
remove if they “coldweld” to the plate.

Submuscular bridge plating⁸¹,¹⁰⁹ allows stable internal fixation with maintenance of vascularity to small fragments of bone, facilitating early healing (Fig 22-29).

Modern techniques of femoral plating,¹⁷⁷
limiting incisions, maintaining the periosteum, using long plates, and
filling only a few selected screw holes, are being adopted by an
increasing number of pediatric orthopaedic trauma surgeons as a
valuable tool to manage length-unstable femoral fractures. Pathologic
fractures, especially in the distal femoral metaphysis, create large
areas of bone loss that can be treated with open biopsy, plate
fixation, and immediate bone grafting.

Kanlic et al.¹⁰⁸
reported a series of 51 patients with submuscular bridge plating with
up to 10 year follow-up; 55% had unstable fracture patterns. There were
two significant complications: one plate breakage (3.5 mm) and one
fracture after plate removal. Functional outcome was excellent, with 8%
significant leg-length discrepancy. Hedequist et al.⁸⁰
reported 32 patients aged 6 to 15 years old, most of whom had fractures
that were comminuted, pathologic, osteopenic, or in a difficult
location. Rozbruch et al.¹⁷⁷
described modern techniques of plate fixation popularized by the AO
Association for the Study of InternalFixation that include indirect
reduction, biologic approaches to internal fixation, and greater use of
blade plates and locked plates (Fig. 22-30).

In very rare situations, such as when there is limited
bone for fixation between the fracture and the physes, locked plating
techniques may be valuable. This technique provides greater stability
by securing the plate with a fixed-angle screw in which the threads
lock to the plate, as well as in the bone. This effectively converts
the screw-plate to a fixed-angle blade plate device. In using this type
of device, one should lock first, then compress, and finally lock the
plate on the opposite side of the fracture. The locked plate can be
used with an extensile exposure or with a submuscular plating
technique, but the latter is more difficult and should be attempted
only when the technique is mastered.

We do not routinely use locking plates unless a
pathologic lesion, severe osteopenia, or severe comminution is present.
Locking screws can cold-weld to the plate, later turning a simple
implant removal into a very difficult procedure involving large
exposures, cutting of the implant, and possible locally destructive
maneuvers to remove the screws.

The technique for submuscular bridge plating of pediatric femoral fractures has been well described in recent publications.¹⁰⁸,¹⁸⁵,¹⁸⁶
The patient is positioned on a fracture table, and a provisional
reduction is obtained with gentle traction. In most cases, a 4.5-mm
narrow, low-contact DCP plate is used. In osteopenic patients or when
there is a proximal or distal fracture, locking plates may be used. A
very long plate, with 10 to 16 holes, is preferred; the plate selection
is finalized by obtaining an image with the plate over the anterior
thigh, assuring that there are six screw holes proximal and distal to
the fracture (although in some more proximal and distal fractures, only
three holes will be available). Depending on the fracture location and
thus the position of the plate, the plate will need to be contoured to
accommodate the proximal or distal femur. The table-top plate bender is
used to create a small flare proximally for the plate to accommodate
the contour of the greater trochanter or a larger flare to accommodate
the distal femoral metaphysis. The plate must be contoured anatomically
because the fixed femur will come to assume the shape of the plate
after screw fixation. A 2- to 3-cm incision is made over the distal
femur, just above the level of the physis. Exposure of the periosteum
just below the vastus lateralis facilitates the submuscular passage of
the plate. A Cobb elevator is used to dissect the plane

between
the periosteum and the vastus lateralis. The fracture site is not
exposed, and, in general, a proximal incision is not required. The
plate is inserted underneath the vastus lateralis, and the femoral
shaft is held to length by traction. The plate is advanced slowly,
allowing the surgeon to feel the bone against the tip of the plate.
Fluoroscopy is helpful in determining proper positioning of the plate.
A bolster is placed under the thigh to help maintain sagittal
alignment. Once the plate is in position and the femur is out to
length, Kirschner wires are placed in the most proximal and most distal
holes of the plate to maintain length (Fig. 22-31).
Fluoroscopy is used to check the AP and lateral views and to be sure
the bone is at appropriate length at this point. A third Kirschner wire
can be used to provide a more stable reduction of the femoral shaft.
Although screws can be used to facilitate angular reduction to the
plate, length must be achieved before the initiation of fixation.

The principles of external fixation are used in choosing
sites for screw fixation. Greater spread of screws increases the
stability of fracture fixation. We generally place one screw through
the distal incision under direct observation. At the opposite end of
the femur, the next most proximal screw is placed to fix length and
provisionally improve alignment. Central screws are then placed, using
a free-hand technique with the “perfect circle” alignment of the plate
over the fracture fragments. Stab holes are made centrally for drill
and screw insertion. Rather than using a depth gauge directly, because
the bone will be pulled to the plate, the depth gauge is placed over
the thigh itself to measure appropriate length of the screw. When
screws are inserted, a Vicryl (Ethicon, Inc., Somerville, NJ) tie is
placed around the shank to avoid losing the screw during percutaneous
placement. Self-tapping screws are required for this procedure. Six
cortices are sought on either side of the fracture.

The postoperative management includes protected weight
bearing on crutches with no need for cast immobilization, as long as
stable fixation is achieved. At times, there is benefit to a knee
immobilizer; however, in general, this is not required. Early weight
bearing in some series of plate fixation has resulted in a low but
significant incidence of plate breakage and nonunion. These
complications should be decreased by a cautious period of postoperative
management.

There are occasional cases with sufficient osteopenia or
comminution to require a locked plate to provide secure fixation. In
using a locked plate submuscularly, a large enough incision must be
used to be sure the bone is against the plate when it is locked. The
articular fragment is fixed first to ensure that the angular
relationship between the joint surface and the shaft is perfect.

Extensive dissection and periosteal stripping during
traditional compression plate application may lead to overgrowth.
Overgrowth was not a significant problem in the series of Kregor et al.,¹¹⁵ with an average increase in length of 0.9 cm (range 0.5 to 1.5 cm), but Ward et al.²⁰⁸ reported several patients with considerable overgrowth (approximately 1 inch), and Hansen⁷⁹
reported overgrowth of an inch in a 12-year-old boy, suggesting that
overgrowth is possible in children over 10 years of age. Eren et al.⁵⁶
reported a series of 40 children aged 4 to 10 years with significant
lengthening on the operated side in 40% of patients, averaging 1.2 cm
(0.4 to 1.8 cm).

Fyodorov et al.⁶⁷
reported implant failure in 2 of 23 femoral shaft fractures treated
with DCPs. One was treated with revision plating and the other with
spica casting; both fractures healed uneventfully. No other
complications were noted in their patients.

Refracture is rare at the end of the plate or through
screw holes, and whether bone atrophy under a plate is caused by stress
shielding or by avascularity of the cortex is unknown. Although still
somewhat controversial, the plate and screws can be removed at 1 year
after fracture to avoid fracture at the end of the plate.

Quadriceps strength after plate fixation appears not to be compromised⁶¹ relative to intramedullary fixation or cast immobilization.

The most common sequela after femoral shaft fractures in
children is leg-length discrepancy. The fractured femur may be
initially short from overriding of the fragments at union; growth
acceleration occurs to “make up” the difference, but often this
acceleration continues and the injured leg ends up being longer. The
potential for growth stimulation from femoral fractures has long been
recognized, but the exact cause of this phenomenon is still unknown.
Growth acceleration has been attributed to age,

sex,
fracture type, fracture level, handedness, and the amount of overriding
of the fracture fragments. Age seems to be the most constant factor,
but fractures in the proximal third of the femur and oblique comminuted
fractures also have been associated with relatively greater growth
acceleration

Some degree of angular deformity is frequent after
femoral shaft fractures in children, but this usually remodels with
growth. Angular remodeling occurs at the site of fracture, with
appositional new bone formation in the concavity of the long bone.
Differential physeal growth also occurs in response to diaphyseal
angular deformity. Wallace and Hoffman²⁰⁷
stated that 74% of the remodeling that occurs is physeal, and
appositional remodeling at the fracture site occurs to a much lesser
degree. However, this appears to be somewhat age dependent. It is clear
that angular remodeling occurs best in the direction of motion at the
adjacent joint.²⁰⁷ That is, anterior
and posterior remodeling in the femur occurs rapidly and with little
residual deformity. In contrast, remodeling of a varus or valgus
deformity occurs more slowly. The differential physeal growth in a
varus or valgus direction in the distal femur causes compensatory
deformity, which is usually insignificant. In severe varus bowing,
however, a hypoplastic lateral condyle results, which may cause a
distal femoral valgus deformity if the varus bow is corrected.

Guidelines for acceptable alignment vary widely. The
range of acceptable anterior and posterior angulation varies from 30 to
40 degrees in children up to 2 years of age (Fig. 22-33), decreasing to 10 degrees in older children and adolescents.¹²⁸
The range of acceptable varus and valgus angulation also becomes
smaller with age. Varus angulation in infants and children should be
between 10 and 15 degrees, although greater degrees of angulation may
have a satisfactory outcome. Acceptable valgus angulation is 20 to 30
degrees in infants, 15 to 20 degrees in children up to 5 years of age,
and 10 degrees in older children and adolescents. Compensation for
deformity around the knee is limited, so guidelines for the distal
femoral fractures should be stricter than for proximal femoral
fractures.

Late development of genu recurvatum deformity of the
proximal tibia after femoral shaft fracture has been most often
reported as a complication of traction pin or wire placement through or
near the anterior aspect of the proximal tibial physis, excessive
traction, pin track infection, or prolonged cast immobilization.²⁰³ However, proximal tibial growth arrest may complicate femoral shaft fracture, presumably as a result of occult

injury.⁹⁴ Femoral pins are preferred for traction, but if tibial pins are required, the proximal anterior tibial physis must be avoided.¹⁴⁶
Femoral traction pins should be placed one or two fingerbreadths
proximal to the superior pole of the patella to avoid the distal
femoral physis.

If significant angular deformity is present after
fracture union, corrective osteotomy should be delayed for at least a
year unless the deformity is severe enough to markedly impair function.
This will allow determination of remodeling potential before deciding
that surgical correction is necessary. The ideal osteotomy corrects the
deformity at the site of fracture. In juvenile patients, however,
metaphyseal osteotomy of the proximal or distal femur may be necessary.
In adolescents with midshaft deformities, diaphyseal osteotomy and
fixation with an interlocking intramedullary nail are often preferable.

According to Verbeek,²⁰⁴
rotational deformities of 10 degrees to more than 30 degrees occur in
one third of children after conservative treatment of femoral shaft
fractures. Malkawi et al.¹²⁹ found
asymptomatic rotational deformities of less than 10 degrees in two
thirds of their 31 patients. Torsional deformity usually is expressed
as increased femoral anteversion on the fractured side compared with
the opposite side, as demonstrated by physical exam; a difference of
more than 10 degrees has been the criterion of significant deformity.
However, Brouwer et al.²⁴ challenged
this criterion, citing differences of 0 to 15 degrees in a control
group of 100 normal volunteers. The accuracy of measurements from plain
radiographs also has been disputed, and Norbeck et al.¹⁵⁶ suggested the use of computed tomographic (CT) scanning for greater accuracy.

Rotational remodeling in childhood femoral fractures is
another controversy in the search for criteria on which to base
therapeutic judgments. According to Davids⁴⁶ and Braten et al.,²³
up to 25 degrees of rotational malalignment at the time of healing of
femoral fractures appears to be well-tolerated in children. In their
patients with more than 25 degrees of rotational malalignment, however,
deformity caused clinical complaints. Davids⁴⁶
found no spontaneous correction in his study of malunions based on CT
measurements, but the length of follow-up is insufficient to state that
no rotational remodeling occurs. Brouwer et al.²⁴ and others¹⁴,⁷⁷,¹⁵⁹,²⁰⁴ reported slow rotational correction over time. Buchholz et al.²⁷
documented 5 children between 3 and 6 years old with increased femoral
anteversion of 10 degrees or more after fracture healing. In 3 of the 5
children, there was full correction of the rotational deformity but the
oldest of the children the deformity failed to correct spontaneously.

Certainly, in older adolescents, no significant
rotational remodeling will occur. In infants and juveniles, some
rotational deformity can be accepted⁶⁰
because either true rotational remodeling or functional adaptation
allows resumption of normal gait. Up to 30 degrees of malrotation in
the femur should result in no functional impairment unless there is
pre-existing rotational malalignment. The goal, however, should be to
reduce a rotational deformity to 10 degrees, based on alignment of the
proximal and distal femur on x-ray, interpretation of skin and soft
tissue envelope alignment, and correct positioning within a cast, based
on the muscle pull on the proximal fragment. The distal fragment should
be lined up with the position of the proximal fragment determined by
the muscles inserted on it (see Fig. 22-3).

Delayed union of femoral shaft fractures is uncommon in
children. The rate of healing also is related to soft-tissue injury and
type of treatment. The time to fracture union in most children is rapid
and age dependent. In infants, the fracture can be healed in 2 to 3
weeks. In children under 5 years of age, healing usually occurs in 4 to
6 weeks. In children 5 to 10 years of age, fracture healing is somewhat
slower, requiring 8 to 10 weeks. Throughout adolescence, the time to
healing continues to lengthen. By the age of 15 years, the mean time to
healing is about 13 weeks, with a range from 10 to 15 weeks (Fig. 22-34).
Application of an external fixation device appears to delay callus
formation and slow the rate of healing. Flexible nailing allows some
motion at the fracture site, promoting extensive callus formation. In
adults, there is an association between nonunion and the use of
nonsteroidal anti-inflammatory drugs (NSAIDs) after injury and delayed
fracture healing,¹,⁶⁰
which is very significant. Although there is not similar data for
children, perhaps patients with risk factors for delayed healing should
avoid NSAIDs.

Bone grafting and internal fixation with either a
compression plate or locked intramedullary nail are the usual treatment
for delayed union in older children and adolescents. Delayed union of a
femoral fracture treated with casting in a child 1 to 6 years of age is
probably best treated by continuing cast immobilization until bridging
callus forms or (rarely) by additional bone grafting.

Nonunions of pediatric femoral fractures are rare.¹²²
They tend to occur in adolescents, in infected fractures, or in
fractures with segmental bone loss or severe soft tissue loss. Tibial
fractures

are
the most common source of pediatric nonunions; femoral fractures
account for only 15% of nonunions in children. Even in segmental
fractures with bone loss, young children may have sufficient osteogenic
potential to fill in a significant fracture gap (Fig. 22-35).¹⁴²
For the rare femoral shaft nonunion in a child 5 to 10 years of age,
bone grafting and plate-and-screw fixation have been traditional
treatment methods, but more recently insertion of an interlocking
intramedullary nail and bone grafting have been preferred, especially
in children over 10 to 12 years of age. Aksoy et al.³
reported a small series of nonunions and malunions salvaged with
titanium elastic nails. Union was achieved in 6 to 9 months in most
cases.

Robertson et al.¹⁷⁴
reported the use of external fixators in 11 open femoral fractures. The
time to union was delayed, but a satisfactory outcome occurred without
subsequent procedures. This supports the belief that the rates of
delayed union and nonunion are low in pediatric femoral fractures,
because open fractures would have the highest rates of delayed union.

Weakness after femoral fracture has been described in
the hip abductor musculature, quadriceps, and hamstrings, but
persistent weakness in some or all of these muscle groups seldom causes
a long-term functional problem. Hennrikus et al.⁸⁸
found that quadriceps strength was decreased in 30% of his patients and
18% had a significant decrease demonstrated by a one-leg hop test.
Thigh atrophy of 1 cm was present in 42% of patients. These deficits
appeared to be primarily related to the degree of initial displacement
of the fracture. Finsen et al.⁶¹ found hamstring and quadriceps deficits in patients with femoral shaft fractures treated with either rods or plates.

Damholt and Zdravkovic⁴⁵ documented quadriceps weakness in approximately one third of patients with femoral fractures, and Viljanto et al.²⁰⁵ reported that this weakness was present whether patients were treated operatively or nonoperatively. Biyani et al.¹⁷
found that hip abductor weakness was related to ipsilateral fracture
magnitude, long intramedullary rods, and, to a lesser degree,
heterotopic ossification from intramedullary rodding. Hedin and Larsson⁸³
found no significant weakness in any of 31 patients treated with
external fixation for femoral fractures based on either Cybex testing
(Cybex International, Inc., Medway, MA) or a one-leg hop test. They
suggested that the weakness seen in other studies may be related to
prolonged immobilization.

Injury to the quadriceps muscle probably occurs at the
time of femoral fracture, and long-term muscle deficits may persist in
some patients regardless of treatment. Severe scarring and contracture
of the quadriceps occasionally require quadricepsplasty.⁹⁹

Infection may rarely complicate a closed femoral shaft
fracture, with hematogenous seeding of the hematoma and subsequent
osteomyelitis. Fever is commonly associated with femoral fractures
during the first week after injury,¹⁹¹
but persistent fever or fever that spikes exceedingly high may be an
indication of infection. One should have a high index of suspicion for
infection in type III open femoral fractures. A series of 44 open
femoral fractures⁹⁸ reported no
infection in types I and II fractures, but a 50% (5 of 10) of type III
fractures developed osteomyelitis. Presumably, this occurs because of
the massive soft tissue damage accompanying this injury.

Pin track infections occasionally occur with the use of skeletal traction, but most are superficial infections that resolve with

local wound care and antibiotic therapy. Occasionally, however, the
infections may lead to osteomyelitis of the femoral metaphysis or a
ring sequestrum that requires surgical débridement.

Nerve and vascular injuries are uncommonly associated with femoral fractures in children.⁴⁹,¹⁰⁴,¹⁷⁶,¹⁹¹ An estimated 1.3% of femoral fractures in children are accompanied by vascular injury⁴⁹,¹⁰⁴,¹⁷⁶,¹⁹¹ such as intimal tears, total disruptions, or injuries resulting in the formation of pseudoaneurysms.¹⁸⁰
Vascular injury occurs most frequently with displaced Salter-Harris
physeal fractures of the distal femur and distal femoral metaphyseal
fractures. If arteriography indicates that vascular repair is necessary
after femoral shaft fracture, open reduction with internal fixation or
external fixation of the fracture is usually recommended first to
stablize the fracture and prevent injury of the repair. Secondary limb
ischemia also has been reported after the use of both skin and skeletal
traction. Documentation of peripheral pulses at the time of
presentation, as well as throughout treatment, is necessary.

Nerve abnormalities reported with femoral fractures in
children include those caused by direct trauma to the sciatic or
femoral nerve at the time of fracture and injuries to the peroneal
nerve during treatment. Weiss et al.²⁰⁹
reported peroneal nerve palsies in 4 of 110 children with femoral
fractures treated with early 90/90 hip spica casting. They recommended
extending the initial short-leg portion of the cast above the knee to
decrease tension on the peroneal nerve.

Riew et al.¹⁷³
reported eight nerve palsies in 35 consecutive patients treated with
locked intramedullary rodding. The nerve injuries were associated with
delay in treatment, preoperative shortening, and boot traction.
Resolution occurred in less than 1 week in 6 of 8 patients.

Many peroneal nerve deficits after pediatric femoral
shaft fractures will resolve with time. In infants, however, the
development of an early contracture of the Achilles tendon is more
likely. Because of the rapid growth in younger children, this
contracture can develop quite early; if peroneal nerve injury is
suspected, an ankle-foot orthosis should be used until the peroneal
nerve recovers. If peroneal, femoral, or sciatic nerve deficit is
present at initial evaluation of a closed fracture, no exploration is
indicated. If a nerve deficit occurs during reduction or treatment, the
nerve should be explored. Persistent nerve loss without recovery over a
4- to 6-month period is an indication for exploration.

Compartment syndromes of the thigh musculature are rare,
but have been reported in patients with massive thigh swelling after
femoral fracture and in patients treated with intramedullary rod
fixation.¹⁴⁴ If massive swelling of
thigh musculature occurs and pain is out of proportion to that expected
from a femoral fracture, compartment pressure measurements should be
obtained and decompression by fasciotomy should be considered. It is
probable that some patients with quadriceps fibrosis¹⁷¹ and quadriceps weakness⁴³,¹⁹⁶ after femoral fracture had intracompartmental pressure phenomenon. Mathews et al.¹³²
reported two compartment syndromes in the “well leg” occurring when the
patient was positioned for femoral nailing in the hemilithotomy
position. Vascular insufficiency related to Bryant traction may produce
signs of compartment syndrome with muscle ischemia.³⁸ Janzing et al.¹⁰⁵
reported the occurrence of compartment syndrome when skin traction was
used for treatment of femoral fractures. Skin traction has been
associated with compartment syndrome in the lower leg in both the
fractured and nonfractured side. It is important to realize that in a
traumatized limb, circumferential traction needs to be monitored
closely and is contraindicated in the multiply injured or head-injured
child. As noted in the spica cast section, several cases of leg
compartment syndrome have been reported after spica cast treatment in
younger children with femoral fractures.

Subtrochanteric fractures generally heal slowly,
angulate into varus, and are more prone to overgrowth. These fractures
offer a challenge, as the bone available between the fracture site and
the femoral neck limits internal fixation options. In younger children,
traction and casting can be successful.⁵⁰
Three weeks of traction is usually necessary. The cast should have a
good valgus mold at the fracture site, and the fracture should be
monitored closely in the first 2 weeks after casting. When the patient
returns for follow-up, if the subtrochanteric fracture has slipped into
varus malangulation, the cast can be wedged in clinic (Fig. 22-36)
or casting can be abandoned for another method. Parents should be
warned that loss of reduction in the cast is quite common, and wedging
in clinic is a routine step in management. An external fixation
strategy can be quite successful if there is satisfactory room
proximally to place pins. Once there is satisfactory callus (about 6
weeks), the fixator can be removed and weight bearing allowed in a
walking spica (long leg cast with a pelvic band and a valgus mold to
stabilize fracture in the first few weeks after external fixator
removal). Flexible nailing can be used, with a proximal and distal
entry strategy (Fig. 22-37). A pitfall in this
fracture is thinking that the proximal fragment appears too short to
use flexible intramedullary nails on the AP x-ray because the proximal
fragment is pulled into flexion by the unopposed psoas muscle. Pombo et
al.¹⁶⁴ reported a series of 13
children, average 8 years old, with subtrochanteric fractures treated
with flexible nailing. Results were excellent or satisfactory in all
cases. Submuscular plating can also produce satisfactory results.¹⁰³
In adolescents, there is insufficient experience with this fracture to
determine at what age intramedullary fixation with a
reconstruction-type nail and an angled transfixion screw into the
femoral neck is indicated. Antegrade intramedullary nail systems place
significant holes in the upper femoral neck and should be avoided.
Unlike subtrochanteric fractures in adults, nonunions are rare in
children with any treatment method.

Supracondylar fractures represent as many as 12% of femoral shaft fractures¹⁸⁸
and are difficult to treat because the gastrocnemius muscle inserts
just above the femoral condyles and pulls the distal fragment into a
position of extension (Fig. 22-38),⁷⁵ making alignment difficult (see Fig. 22-3). The traditional methods of casting and single-pin traction may be satisfactory in

young children (Fig. 22-39).
As mentioned in the external fixation section, supracondylar fractures
through a benign lesion are safely and efficiently treated with a brief
period (4 to 6 weeks) of external fixation (Fig. 22-40),
followed by a walking cast until the callus is solid and the pin sites
are healed. In other cases, internal fixation is preferable, either
with submuscular plating (see Figs. 22-29 and 22-41)
and fully threaded cancellous screws (if there is sufficient
metaphyseal length) or with crossed smooth Kirschner-wires transfixing
the fracture from the epiphysis to the metaphysis, as described for
distal femoral physeal separations.¹⁸¹
If there is sufficient metaphyseal length, flexible nailing can be used
so long as fixation is satisfactory. The flexible nails can be placed
antegrade as originally described or retrograde if there is
satisfactory distal bone for fixation near the nail entry site.
Biomechanically, retrograde insertion is superior.¹⁴⁰ Pathologic fractures in this area are common, and an underlying lesion should always be sought.

Open femoral fractures are uncommon in children because
of the large soft tissue compartment around the femur. Proper wound
care, débridement, stabilization, and antibiotic therapy are required
to reduce the chance of infection.⁷⁵ In a study by Hutchins et al.,⁹⁸
70% of children with open femoral fractures had associated injuries and
90% were automobile related. The average time to healing was 17 weeks,
and 50% of the Gustillo type III injuries developed osteomyelitis.

External fixation of open femoral shaft fractures
simplifies wound care and allows early mobilization. The configuration
of the external fixator is determined by the child’s size and the
fracture pattern. Generally, monolateral half-pin frames are
satisfactory, but thin-wire circular frames may be necessary if bone
loss is extensive. External fixation provides good fracture control,
but, as always, family cooperation is required to manage pin and
fixator care.

Plate fixation also allows early mobilization, as well
as anatomic reduction of the femoral fracture. Wound care and treatment
of other injuries are made easier in children with multiple trauma.
However, this is an invasive technique with the potential for infection
and additional injury to the already traumatized soft tissues in the
area of the fracture. In emergency situations, plate fixation or
intramedullary fixation can be used for Gustillo-Anderson types I and
II fractures; type III fractures in older adolescents are better suited
for external fixation or intramedullary

nailing. Plate breakage can occur if bone grafting is not used for severe medial cortex comminution.

In older adolescents, submuscular plating or
trochanteric-entry nailing is often the optimal treatment choice.
Closed nailing after irrigation and drainage of the fracture allows
early mobilization and easy wound care in patients with
Gustillo-Anderson types I, II, IIIA, and IIIB injuries, but the risk of
osteonecrosis must be recognized.

For patients with osteogenesis imperfecta who have
potential for ambulation, surgical treatment with Rush, Bailey-Dubow,
or Fassier rods (see Chapter 6) is recommended
for repeated fractures or angular deformity. Cast immobilization is
minimized in patients with myelomeningocele or cerebral palsy because
of the frequency of osteoporosis and refracture in these

patients.
If possible, existing leg braces are modified for treatment of the
femoral fracture. In nonambulatory patients, a simple pillow splint is
used.

These rare injuries occur when ipsilateral fractures of
the femoral and tibial shafts leave the knee joint “floating” without
distal or proximal bony attachments. They are high-velocity injuries,
usually resulting from collision between a child pedestrian or cyclist
and a motor vehicle. Most children with floating knee injuries have
multiple-system trauma, including severe soft tissue damage, open
fractures, and head, chest, or abdominal injuries.

Except in very young children, it is usually best to fix
both fractures. If both fractures are open, external fixation of both
the tibial and femoral fractures may be appropriate. If immediate
mobilization is necessary, fixation of both fractures with external
fixation, intramedullary nails, compression plates, or any combination
of these may be indicated.

Letts et al.¹²¹
described five patterns of ipsilateral tibial and femoral fractures and
made treatment recommendations based on those patterns (Fig. 22-42). Because of the high prevalence of complications after closed treatment, Bohn and Durbin²⁰ recommended open or closed reduction and internal fixation of the femoral fracture in older children. Arslan et al.⁷
evaluated the treatment of the “floating knee” in 29 consecutive cases,
finding that those treated operatively had a shorter hospital stay,
decreased time to weight bearing, and fewer complications than those
managed with splinting casting or traction. Arslan et al.⁷
demonstrated that open knee fracture rather than ligamentous injury was
a risk factor for poor outcome and that angulation was a predictor of
future compromise of function.

Bohn and Durbin²⁰
reported that of 19 patients with floating knee injuries, at long-term
follow-up 11 had limb-length discrepancy secondary to either overgrowth
of the bone after the fracture or premature closure of the ipsilateral
physis (7 patients), genu valgum associated with fracture of the
proximal tibial metaphysis (3 patients), or physeal arrest (1 patient).
Four patients had late diagnosis of ligamentous laxity of the knee that
required operation. Other complications included peroneal nerve palsy,
infection, nonunion, malunion, and refracture.

In a study of 387 previously healthy children with
femoral fractures, the authors evaluated the effect of stabilization on
pulmonary function. Patients with severe head trauma or cervical spine
trauma are at greatest risk for pulmonary complications. Timing of
treatment of femoral fractures appears to not affect the prevalence of
pulmonary complications in children. Mendelson et al.¹⁴¹
similarly showed no effect of timing of femoral fixation on long-term
outcome, but early fracture fixation did decrease hospital stay without
increasing the risk of central nervous system or pulmonary
complications.